Provider Demographics
NPI:1356494892
Name:MOHAMMADI, TANAZ (OD)
Entity Type:Individual
Prefix:
First Name:TANAZ
Middle Name:
Last Name:MOHAMMADI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 E ST
Mailing Address - Street 2:SUITE 285
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2850
Mailing Address - Country:US
Mailing Address - Phone:415-454-5586
Mailing Address - Fax:
Practice Address - Street 1:901 E ST
Practice Address - Street 2:SUITE 285
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2850
Practice Address - Country:US
Practice Address - Phone:415-454-5586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT13128TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
W0P13128Medicare UPIN